All Causes/Sites of Pudendal Nerve Compression/Neuralgia

[shawnmellis]

Hi, So far, from my research I have found the following below as all possible sites and causes of Pudendal Nerve Entrapment/Compression or Pudendal Neuralgia: Some people may not want to know all the possible causes and sites of compression or neuralgia, but I do, because I think it may helps some of us with the diagnosis and cause of pudendal entrapment or neuralgia so I started this list. This is not a complete list, but a rather good one and anybody who knows of any other causes backed with evidence from doctors, patients after surgery or surgeons, or other please let me know and post it here. Thanks

All Areas and Causes of Pudendal Nerve Compression/Entrapment/Neuralgia
1. Compression of Pudenal Nerve by Fibrosis(scar tissue) of part of the Sacro-Spinous Ligament(Dr. Eric Bautrant, France)
2.Compression of Pudendal Nerve by Fibrosis(scar tissue) in the Alcock's canal (Dr. Eric Bautrant France)
3. Compresseion of Pudendal Nerve by spine or sacral area (lumbar spine disc area or sacral disc area)
4. Compression of Pudendal Nerve by Pirformis Muscle abnormality or Pirformis Muscle Syndrome(Dr. Eric Bisschop, France)
5. Compression of Pudendal Nerve by fascias of the muscle obturatorius internus, which constitutes the Alcock's (Pudendal) Canal, (Dr. Eric Bisschop, France) This may be the same as area/cause as number 2 listed above. I'm not sure
6. Compression of Pudendal Nerve by being too close (too tight a space between) the Sacrotuberous and Sacrospinous ligaments (Dr. Eric Bisschop, France)
7. Compressioin from A dysfunctionnal state (of the piriformis) can generate a repeated hypertension of the muscle with hypertrophia. If it has a consequence on the ?bony? structure it can close the interligamentery grip in which the pudendal nerve passes. The pudendal nerve is already weaken at the level of the infrapiriformis. (Guy de Bishops - Pierre's)
8. Compression of Pudendal Nerve at area of Pubic Ramsus Tunnel (Dorsal Branch of Pudendal Nerve), Upper perineum, area, Dr. Lee Dellon, Baltimore, MD
9. Compression of Pudendal Nerve at Perineal Branch of Pudendal Nerve (Dr. Eric Bautrant)
10. Compression of Pudendal Nerve at Rectal Branch of Pudendal Nerve
11. Compression of Pudendal Nerve by Scar tissue surrounding any are of main pudendal nerve or its branches
12. Compression of Pudendal Nerve can be caused by pregnancy, scarring due to surgery, accidents and surgical mishaps (Wikipedia)
13. Compression of Pudenal Nerve can be caused by Anatomic abnormalities can result in PNE due to the pudendal nerve being fused to different parts of the anatomy (Wikipedia)
14.Compression of Pudendal Nerve by being trapped between the sacrotuberous and sacrospinalis ligaments(Wikipedia)
15.Compression of Pudendal Nerve by activities such as bicycling causing thickening of the sacrotuberous and/or sacrospinous ligaments and trap the nerve between them, resulting in PNE (Wikipedia)
16. Compression of Pudendal Nerve as it passes under the piriformis muscle (http://www.nervemed.com)

17.Compression of the Pudendal Nerve as it travels across the obturator foramen within the Alcox canal (http://www.nervemed.com)
18. Compression of the Pudendal Nerve by irritation of the Impar ganglion on the internal surface of the coccyx.C (http://www.nervemed.com)
19. Compression of the Pudenal Nerve upon exit from Alcox canal and branching in the perineal area (between the legs) (http://www.nervemed.com)
20. Compression of the Pudendal Nerve by Sacroiliac Joint Dysfunction. Clinically, we have observed that symptoms of PN are often associated with sacro-iliac joint (SIJ) dysfunctions. We propose that the pudendal nerve could be compromised by dysfunction of the SIJ. Potential mechanisms could involve soft tissue damage resulting in stiffening of fibrotic scar tissue at the SIJ causing SIJ malalignment. The putative reasoning suggests that if physical stress causes the sacrum to nutate or the ilium to posteriorly rotate, tension is placed on the nerve as it moves between the sacrospinous and the sacrotuberous ligaments. The suggestion is that the sacrospinous ligament squeezes the pudendal nerve against the sacrotuberous ligament, causing sensitised and inappropriate pain patterns. (http://www.peterdornanphysio.com.au/pudendal.html)
21.Of particular interest, one perineal branch of the nerve, the inferior pudendal (long scrotal nerve) curves below and in front of the ischial tuberosity, pierces the fascia lata and runs to the skin of the scrotum in the male and the labium majus in the female, scrotal pain (and labia pain) being one of the consistent symptoms of this condition. (http://www.peterdornanphysio.com.au/pudendal.html)
22. As several of the lumbar nerves, in particular, the posterior femoral cutaneous nerve, inferior gluteal nerve, the tibial (medial popliteal) nerve, the common peroneal (lateral popliteal) nerve and the perforating cutaneous nerve, derive at least one slip from S2,S3 or S4, the patient may also complain of pain in the lower back, groin, buttocks, posterior thigh, calf or ankle. This may be referred either by neural convergence, by direct injury to the lumbar area, or by chronic SIJ damage impacting on L5S1, thereby interfering with local emitting lumbar nerves. Given the wide range of enervation of the SIJ and its adjacent neural structures, SIJ capsular stimulation may refer various pain patterns to the buttock, groin, thigh, calf or foot. (http://www.peterdornanphysio.com.au/pudendal.html)
23. Compression of the Cluneal Nerve (Dr. Lee Dellon Baltimore)
24. Autoimmune disorders
25. Nerve compression by Varices(enlarged veins) on Nerve Dr. Aszmann,(Austria) Dr. Possover M.(Switzerland) Dr. Aszmann has confirmed 2 cases of this occurrence to me personally. Although Varices may or may not be a more rarer cause of a branch of the pudendal nerve to be compressed, it has been confirmed from surgery by Dr. Possover and Dr. Aszmann. Having said that it is best probably to let the nerve surgeons handle the Varices in these areas so close to the nerves and Aszmann ligates and resects it if he finds it. I'm not sure how other nerve surgeons would handle the enlarged veins if they found it to be the cause of compression, but it would probably be the same way.
Varices Have Been A Confirmed Cause of Pudendal Compression.

Although it may or may be rarer than other causes, branches of the Pudendal
nerve have been confirmed to be compressed by Varices(enlarged veins) Dr.
Aszmann,(Austria) and Dr. Possover M.(Switzerland) have both confirmed this
from surgery. Dr. Aszmann has confirmed 2 cases of this occurrence to me
personally. Having said that it is best probably to let the nerve surgeons
handle the Varices in these areas so close to the nerves and I'm pretty sure that
Aszmann ligates and resects it if he finds it to be the problem. I'm not sure
how other nerve surgeons would handle the enlarged veins if they found it to be
the cause of compression, but it would probably be the same way. Dr. Dellon has
also said that if the Varices are the cause of the compression that he can also
take care of it during surgery.

I don't think that Aszmann or some other sugeons recommend doing sclerosing
of the vein as it may possibly cause more scare tissue, and it is probably best
to let them do the surgery in case Varices is not the cause of the compression
and the only way to really know for sure is by surgery that we know of so far,
since nobody has confirmed they have gotten better by getting the veins taken
care of by sclerosing or embolisation alone so far anyways.

Here is a sample of my conversation with Dr. Aszmann
Hi Dr. Aszmann, Have you ever operated on somebody with varices (pelvic
congestion) in the pelvis or dorsal branch of pudendal nerve in which case the
varices (enlarged veins) was the only cause of the compression of the dorsal
branch of the nerve or another nerve in the pelvis? I'm just curious. Thanks

Yes, a man and a woman. Both had the diagnosis “venous congestion in the
urogenital diaphragm” in their MRI report. Intraoperatively the woman had
varicous veins and a rather large pudendal artery bilaterally. The man had a
very bulbous ischiocavernous body on the affected side- the other being almost
normal. In men the space available is very tiny, since the canal of the dorsal
nerve is anatomically tight already. The woman had tried intravasal application
of a foam to obliterate the venous network- to no avail hoewever. I have
operated her just before the summer and she is fine so far. The man I have not
heard of after a 3 month follow-up phone call.
He also said he has seen enlarged blood vessels causing compression in other areas of the body in his email he sent to me . Here is the rest of his email There are many other nerve compressions caused by blood vessels in other body parts. Some of them even have a name. In the upper extremity the radial nerve can be compressed by prominent vessels- if so these vessels are then called “the leash of Henry” Also in the tarsal tunnel for the tibial nerve this is known cause of nerve entrapment.

Hope this helps everyone to know that there is another possible cause of
compression other than ligaments/tendons/scar tissue at leasst in the area of
the dorsal branch of the Pudendal Nerve.
He also said he has seen enlarged blood vessels causing compression in other areas of the body in his email he sent to me . Here is the rest of his email There are many other nerve compressions caused by blood vessels in other body parts. Some of them even have a name. In the upper extremity the radial nerve can be compressed by prominent vessels- if so these vessels are then called “the leash of Henry” Also in the tarsal tunnel for the tibial nerve this is known cause of nerve entrapment.

[helenlegs 11]

Wow! hard work Shawn, well done. I hoped to get a similar list going some time ago asking people what different entrapments they'd had diagnosed but didn't get very far
Wouldn't it be fantastic if people could associate certain symptoms with certain entrapments (obviously only as a guide, and some entrapments may have the same symptoms anyway) Any physio could be better targeted perhaps.
I guess the best thing would be to be able to offer a potential dividing line between the type of symptoms that could be associated with those that may benefit from TG surgery and those that may not, saving some from unnecessary surgery. I know I have jumped to surgery here and of course that is the last resort option as many compressions can be addressed with physio but when everything else has been tried and true entrapment is suspected.
I know it will probably be impossible to have a definitive list but this has got to help.

[calluna]

I think that from what I've heard, the main problem with trying to identify the site of compression with any certainty is the fact that anatomy can vary such a lot.

Also, not all Pudendal Neuralgia is caused by compression. So there is another substantial category there. (I have a particular interest in this one!) We could go on for ever.....

[Violet M]

Great list, Shawn. I like the fact that you have backed it up with references although I would not consider wiki to be a very reliable source knowing some of what goes on behind the scenes there.

[shawnmellis]

Hi everyone,
Another possible cause of PN or PNE is from the adductor (inner thigh muscles that connnect to your lower and upper pelvis bones). For about 1 year I mainly just had pain in my upper perineum and some in lower perineum that I noticed when sitting. 2 months ago, I reinjured myself doing gardening and I have had a new burning pain in a different location which is both thighs in the upper back part of them and also in the inner thigh area for both thighs. I first injured myself standing up from a squatting position 1 year ago and I felt a pull and pain in my left adductor muscle (thigh muscle) which connects to the lower and middle part of pelvis. When I reinjured myself 2 months ago, I also felt a pull and pain in this area of my left thigh muscle. My MRI showed that I have tendinosis on both of my upper thigh muscles. Tendinosis means chronic degeneration or tendon injury, so that is most likely somehow related to the cause of my pudendal neuralgia. My MRI showed varices (enlarged veins) on both sides of my pelvis in the dorsal branch of the pudendal nerve all the way to just outside the alcocks canal, which sometimes indicates entrapment in the location of varices. Dr. Dellon, said that adductor muscles can entrap your pubic ramus tunnel (dorsal branch of pudendal nerve) and there is another nerve close to there also called the perineal nerve which branches out to the femoral nerve (thigh nerve), so anybody with similar problems like mine could have compression of both your dorsal nerve and your perineal branch of the nerve (which is outside the distal part of alcock's canal closer to dorsal branch of pudendal nerve and not at the entrance to the alcocks canal) which branches to the femoral nerve which goes to the back of your thigh (posterior femoral nerve) and also inner thighs. It could also possibly be your obturator nerve or another sciatic nerve. As far as the sciatic nerve goes though, you should probably have pain that goes all the way down your legs to your feet from that and not just in your buttocks, back thigh and inner thigh. As far as obturator, you usally have more just buttock pain and not as much thigh pain My pain is in my perineum, addductor muscles, back thigh, inner thigh, some of buttocks and sometimes front, which can be the perineal nerve radiating to the femoral nerve branch or it could just be the femoral nerve itself compressed separately or obturator nerve. This is what I am trying to rule out and figure out now, but I am pretty sure it is the perineal nerve which is in the lower perineum area by your pubic ramus bone area, which branches to the femoral nerve of your thigh. Any thoughts? You guys can email me at shawnmellis@gmail.com if you want any time and feel free to join me also at a facebook group for pudendal neuralgia called Pudendal Neuralgia Support at http://www.facebook.com/groups/10383831 ... 838315764/ to also chat online with me. Take care and hope to hear from you soon
Shawn

[shawnmellis]

For about 1 year I mainly just had pain in my upper perineum and some in lower perineum that I noticed when sitting. 2 months ago, I reinjured myself doing gardening and I have had a new burning pain in a different location which is both thighs in the upper back (posterior) part of them and also in the inner thigh area for both thighs. I first injured myself standing up from a squatting position 1 year ago and I felt a pull and pain in my left adductor muscle (thigh muscle) which connects to the lower and middle part of pelvis. When I reinjured myself 2 months ago, I also felt a pull and pain in this area of my left thigh muscle. My MRI showed that I have tendinosis on both of my upper thigh muscles. Tendinosis means chronic degeneration or tendon injury, so that is most likely somehow related to the cause of my pudendal neuralgia. My MRI showed varices (enlarged veins) on both sides of my pelvis in the dorsal branch of the pudendal nerve all the way to just outside the alcocks canal, which sometimes indicates entrapment in the location of varices. Dr. Dellon, said that adductor muscles can entrap your pubic ramus tunnel (dorsal branch of pudendal nerve) and there is another nerve close to there also called the perineal nerve which branches out to the femoral nerve (thigh nerve), so anybody with similar problems like mine could have compression of both your dorsal nerve and your perineal branch of the nerve (which is outside the distal part of alcock's canal closer to dorsal branch of pudendal nerve and not at the entrance to the alcocks canal) which branches to the femoral nerve which goes to the back of your thigh (posterior femoral nerve) and also inner thighs. It could also possibly be your obturator nerve or another sciatic nerve. As far as the sciatic nerve goes though, you should probably have pain that goes all the way down your legs to your feet from that and not just in your buttocks, back thigh and inner thigh. As far as obturator, you usally have more just buttock pain and not as much thigh pain My pain is in my perineum, addductor muscles, back thigh, inner thigh, some of buttocks and sometimes front, which can be the perineal nerve radiating to the femoral nerve branch or it could just be the femoral nerve itself compressed separately or obturator nerve. This is what I am trying to rule out and figure out now, but I am pretty sure it is the perineal nerve which is in the lower perineum area by your pubic ramus bone area, which branches to the femoral nerve of your thigh. Any thoughts? You guys can email me at shawnmellis@gmail.com if you want any time and feel free to join me also at a facebook group for pudendal neuralgia called Pudendal Neuralgia Support at http://www.facebook.com/groups/10383831 ... 838315764/ to also chat online with me.

I think I may have found something useful. I got this from my Peripheral Nervous System Book I read. This is what is says:
"The POSTERIOR FEMORAL CUTANEOUS NERVE" is formed by ventral rami branches from the S1, S2, and S3 spinal segments. This POSTERIOR FEMORAL CUTANEOUS NERVE is the ORIGIN OF THE INFERIOR CLUNEAL NERVES, which are cutaneous nerves supplying skin of the inferior buttock. The POSTERIOR FEMORAL CUTANEOUS NERVE continues DISTALLY and gives MULTIPLE BRANCHES that supply skin of the POSTERIOR EXTERNAL GENITALIA AND POSTERIOR THIGH."

Based on this it looks like the POSTERIOR FEMORAL CUTANEOUS NERVE can be compressed OR the INFERIOR CLUNEAL NERVE can be compressed causing similar symptoms of thigh and buttocks pain since the POSTERIOR FEMORAL CUTANEOUS NERVE is the origin of the INFERIOR CLUNEAL NERVES that supply skin to the inferior buttock. Also, based on this if your POSTERIOR FEMORAL CUTANEOUS NERVE is compressed you can also have pain in your skin of the POSTERIOR EXTERNAL GENITALIA INCLUDING THE PERINEUM, BULBOSPONGIOUS MUSCLE AND THE POSTERIOR THIGH.

So, this is a very possible explanation to me of other areas other than the traditonal rectal, Alcock's canal, and the part of the pudendal nerve between the Sacrospinous and Sacrotuberous Ligaments that can also cause pain in the perineum and pain in the thigh. I also read on Wikipedia (and saw in anatomy diagrams) that the Perineal branch of the Pudendal Nerve goes to the Bulbospongious muscle which is the superficial (area close to skin) muscle that goes all the way vertically and centrally from just above the rectum to right below the genitals, which is where I have a lot of pain. You can go to wikipedia at http://en.wikipedia.org/wiki/Deep_branc ... neal_nerve to see where it says this. I also read somewhere that this perineal branch of the pudendal nerve branches to the POSTERIOR FEMORAL NERVE. I think that anyone with pain in the thighs or pain in the perineum should print this out and show it to the PNE specialist they see. I got this from a Book called "A Comprehensive Introduction to The Peripheral Nervous System" by Charles A. Henderson M.D. on page 440. It is the latest edition of the book that I purchased from Amazon.com Anybody have any thoughts?

[kathyd]

Hi Shawn,
Thx for all the research on the areas of compression. We have very similar MRI results . I have the varices in the same area from what you described. I have pain which started in this order. 1- sit bones 2 peri -labia and most recently anal area. The latter just in past 6 weeks.. I have tight adductors and hamstrings and I think that mild tendinosis was noted on my MRIs I have never had a severe injury but instead can cite a few falls in life that could have been bad, but I didn't get more thana scratch or bruise... They occurred many years ago..
As of now I can't sit period. I type this laying down.. I also can't stand for long. Standing has gotten worse since recently as well.
Im the one who had the embolisation without relief...
Would love to speak via email...Im also new to your facebook grp but not savvvy!! sHope to exchange ideas with you, as I am in god -awful pain am very demoralized. Have some serious choices to make
Ths for all the research!
Kathy

[Faith]

Hi Shawn,
Thx for all the research on the areas of compression. We have very similar MRI results . I have the varices in the same area from what you described. I have pain which started in this order. 1- sit bones 2 peri -labia and most recently anal area. The latter just in past 6 weeks.. I have tight adductors and hamstrings and I think that mild tendinosis was noted on my MRIs I have never had a severe injury but instead can cite a few falls in life that could have been bad, but I didn't get more thana scratch or bruise... They occurred many years ago..
As of now I can't sit period. I type this laying down.. I also can't stand for long. Standing has gotten worse since recently as well.
Im the one who had the embolisation without relief...
Would love to speak via email...Im also new to your facebook grp but not savvvy!! sHope to exchange ideas with you, as I am in god -awful pain am very demoralized. Have some serious choices to make
Ths for all the research!
Kathy

Have you considered that the Posterior Femoral Cutaneous Nerve could be part (of all) of your problem? I have been researching a lot about this nerve as I have pain in the areas you have described (as well as others). The PFCN divides into the inferior cluneal and perineal branches. This post I made has an article by Dr. Hibner that talks a little more about it http://www.pudendalhope.info/forum/view ... f=5&t=2253 and also this article http://www.pudendalhope.org/sites/defau ... NTubbs.pdf

I think it's interesting that Dr. Potter never even mentioned this nerve on PaulSa's MRI report especially since he has sit bone pain. Of course the hamstring tendinosis could be part of the issue.